Tuesday, November 29, 2016

In the ongoing work to increase clinical referrals to the many high-quality, community evidence-based programs that help people prevent onset of or manage their diabetes, we have identified several systematic barriers that we are working to address:

Barrier

Activities to Address Barrier

1. The community programs are grant funded (leading to
clinicians' perception, and sometimes
the reality, that they change
frequently, are not reliably available)

1.
We are communicating with providers about grant life and local, ongoing
program support

2. Electronic Medical Records do not have a place for this kind
of community resource referrals, making it difficult to institutionalize
community referrals

2.
Each practice will address this differently. One partner practice has created
a Diabetes reference folder in the EHR where clinicians can find referral
information.

3. There is no single entry point, no one phone number to call
to refer a client to these various diabetes prevention and management
programs.

3.
Again, practices are addressing this differently. We are working with 211 so
that they can be a single clinical referral point. One practice has chosen to
work closely with and refer to just one community program that best fits
their clients' demographics, eliminating this problem.

4. Primary Care providers assume in-house educators or
endocrinology referrals are providing full range of support--from med
titration to nutrition and activity coaching, though this is often not the
case.

4.
CHIP workgroup is focusing on long-term culture-change, as ACO looks more and
more to population health, community diabetes programs are increasing their
own visibility and developing relationships with primary care providers to
extend support for clients outside clinic walls.

For more information about this workgroup, its goals, action items, etc., please click "Workgroup Overview" on the right sidebar. You can also click here to see the Community Scorecard--local diabetes data, active partners, current initiatives and community strategies.